Faculty Bibliography

BACKGROUND: A small subset of patients account for a substantial proportion of hospital readmissions. Programs to reduce utilization among this subset of frequently hospitalized patients have the potential to improve health and reduce unnecessary spending.

The ability to decide advantageously among options that vary in both their risks and rewards is critical for survival and well-being. Previous work shows that some forms of risky decision-making are robustly modulated by monoamine signaling, but it is less clear how monoamine signaling modulates decision-making under risk of explicit punishment. The goal of these experiments was to determine how this form of decision-making is modulated by dopamine, serotonin, and norepinephrine signaling, using a task in which rats choose between a small, 'safe' food reward and a large food reward associated with variable risks of punishment. Preference for the large, risky reward (risk-taking) was reduced by administration of a D2/3 dopamine receptor agonist (bromocriptine) and a selective D2 agonist (sumanirole). The selective D3 agonist PD128907 appeared to attenuate reward discrimination abilities but did not affect risk-taking per se. In contrast, drugs targeting serotonergic and noradrenergic signaling had few if any effects on choice behavior. These data suggest that in contrast to other forms of risky decision-making, decision-making under risk of punishment is selectively modulated by dopamine signaling, predominantly through D2 receptors.

Many integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization. We found that programs evolved over time, eventually converging on the implementation of the following elements: 1) an interdisciplinary care team, 2) chronic disease management, 3) comprehensive patient assessment and evaluation, 4) care and case management, 5) transitional care support, 6) preventive home visits, 7) pharmaceutical services, 8) chronic disease self-management, 9) caregiver support services, 10) health coaching, and 11) advanced care planning. The teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address psychosocial needs of these complex patients. Having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites. In future iterations of these programs, VHA intends to standardize staffing and key features to develop a scalable program that can be disseminated throughout the system.

: media-1vid110.1542/5839981580001PEDS-VA_2018-0290Video Abstract OBJECTIVES: To determine the association of antibiotic use with weight outcomes in a large cohort of children.

Companion animals are likely relevant in the transmission of antimicrobial resistant bacteria in the community. Enterobacter xiangfangensis ST171, a clone that has been implicated in clusters of infections in humans, was isolated from two dogs with clinical disease in Ohio, U.S. The canine isolates contained IncHI2 plasmids encoding bla_KPC-4 Whole genome sequencing was used to put the canine isolates in phylogenetic context with available human ST171 sequences, as well as characterize their bla_KPC-4 plasmids.

BACKGROUND:Longitudinal standardized patient (LSP) experiences mimic clinical practice by allowing students to interact with standardized patients (SPs) over time. LSP cases facilitate practice, assessment, and feedback in clinical skills and foster an appreciation for the continuum of care. OBJECTIVE:We sought to characterize the nature of relationship-building, feedback, and continuity among all stakeholders participating in a single LSP program. DESIGN/METHODS:We developed and implemented a novel LSP program. Students encountered two LSP characters six times each during the first 2 years of medical school, though continuity pairings of students, SPs, and faculty were frequently not possible. Focus groups were held with second-year medical students (N = 15), core faculty who coached these students in LSP encounters (N = 8), and SPs who had played the role of either LSP character (N = 10) participated. Results were analyzed thematically using a template analysis approach. RESULTS:The longitudinal nature of the experience reinforced the importance of student growth over time, the key role of faculty and SPs in providing feedback, and the tension between feedback and assessment. Students reported that LSP cases encouraged practice and feedback. SPs felt wedded to the longitudinal characters. Continuity pairings were recommended by all stakeholders to increase authenticity and promote relationship-building. CONCLUSION/CONCLUSIONS:Stakeholders observed that the LSP cases brought some sense of continuity missing in other clinical skills encounters which helped prepare students for patient care. Continuity pairings of students, faculty, and SPs were recommended to enhance relationship-building and feedback.

Background/UNASSIGNED:) that were TZP-NS but ceftriaxone-susceptible (CRO-S). Methods/UNASSIGNED:. Results/UNASSIGNED:= .04). Thirty-day mortality after TZP-NS/CRO-S bacteremia was 25%, which was similar to control groups and was similar in patients treated empirically with BL/BLIs compared with those treated with cephalosporins or carbapenems. Targeted therapy with cephalosporins did not yield a higher 30-day mortality rate than carbapenem therapy. Conclusions/UNASSIGNED:are emerging causes of bacteremia, and further research is needed to better understand the epidemiology, resistance mechanisms, and clinical impact of these strains.

BACKGROUND:Objective review of orthopedic resident medical records revealed significant variation in quality of clinical notes suggesting that the implementation of the electronic medical record (EMR) had altered resident perceptions of the purpose of clinical documentation. OBJECTIVE:The purpose of this study was to assess resident perceptions of the purpose and use of the EMR. METHODS:An 84-item survey was developed based on previously validated surveys. All 62 orthopedic residents within one academic institution completed the survey. Questions were divided into six domains and domain scores were calculated by summing responses within each domain; a more negative response on the Likert scale received a higher score. Scores were compared across postgraduate year (PGY). RESULTS:Survey results revealed that most residents agreed that they generally write good patient care notes, their notes contribute to the care of the patient, and as physicians they feel responsible for the accuracy of the information they enter into the EMR. However, residents were divided as to whether they have enough time to write a good patient care note. Domain scores did not significantly differ by PGY indicating that perceptions toward the EMR do not change even as residents increase their knowledge of orthopedics and become more skilled physicians. CONCLUSIONS:Although residents recognize that the information they enter in the EMR is valuable for patient care and safety, some feel unable to consistently utilize the EMR to its full potential due to time constraints.

Background: Diagnostic errors have a significant impact on our health care system with cognitive errors contributing to the majority of cases. Educators have theorized that interventions grounded in dual process theory (DPT) may improve the clinical reasoning (CR) process of physicians but little empirical evidence of this theory exists.
Method(s): This study was a quasi-experimental design in the New York University Internal Medicine Residency Program from June 2017- January 2018. We implemented two educational interventions in CR grounded in DPT during this 6-month period, leading to a natural experiment with three groups: no intervention (N = 25), partial intervention (received part 1, N = 23), and full intervention (received part 1 and part 2, N = 23). The educational interventions covered the concepts of DPT, impact of diagnostic errors, and case-based discussions introducing techniques to develop fast and slow thinking. We used the diagnostic thinking inventory (DTI) at baseline (a 41 item self-assessment questionnaire to assess one's approach to CR). At 6 months, participants completed a follow-up DTI and a post-survey assessing their ability to apply concepts to cases as well as workplace experiences of CR teaching. Participants who completed pre- and post-surveys were included in the analysis. Case examples were scored by two independent reviewers blinded to group status (Table). Differences between groups were analyzed using a one-way analysis of variance.
Result(s): Those in the full intervention group reported more teaching of DPT on attending rounds and in conference than the partial intervention and no intervention groups (60% often or always taught compared to 25% and 8.3%, p = 0.002; 73.3% often or always taught compared to 58.3% and 33.3%, p = 0.033, respectively). Otherwise workplace experiences were not significantly different between the groups. There was a significant difference between groups in ability to apply concepts to cases with a medium to large effect size (Table). There was also a significant difference in giving case examples in problem representation format with a large effect size (Table). There was no significant difference in change in DTI scores (mean change in score no intervention 7.0 (SD 16.3), partial intervention 8.8 (SD 9.8), full intervention 7.8 (SD 12.0), p = 0.946).
Conclusion(s): This study provides evidence that interns who participated in a CR curriculum grounded in DPT were effective in applying principles of CR in cases from their own clinical practice and supports the argument that we should be designing educational interventions in CR grounded in DPT. Subsequent studies would need to assess further impact on patient outcomes. (Figure Presented)